What can UK learn from Dutch approach to end-of-life care?

England’s NHS will need up to 40,000 more beds — the equivalent of about 65 more hospitals — by the end of the decade, as it confronts a rising tide of illness and death among the “baby boomer” generation, according to new research.

The findings underline the tension between easing the UK’s fiscal burden and satisfying an ever greater need for public services from an ageing population, as Conservative leadership contenders compete to promise lower taxes.

Experts believe the taxpayer-funded health service must learn lessons from other countries that have proved more effective at building bridges between hospital and community care, relieving pressure on hospital beds.

Outgoing prime minister Boris Johnson won the 2019 general election partly on a promise to build 40 new hospitals but the Health Foundation, which conducted the research for the FT, said its calculations suggested “a far larger increase in bed supply” was needed.

Over the past 30 years, the total number of available beds in England has more than halved but investment in community services to cushion the impact of cuts has failed to materialise.

This stands in contrast to other countries such as the Netherlands, Sweden and Denmark, which have similar levels of beds per head of population to the UK, but have strengthened out-of-hospital care to ensure people can be cared for — and eventually die — at, or closer to, home.

The Foundation’s analysis suggested that between 23,000 and 39,000 more general and acute beds would be needed, representing an increase of between 20 per cent and 35 per cent on current numbers.

Anita Charlesworth, Health Foundation director of research, estimated the pricetag at between £17bn and £29bn but cautioned that rising inflation might significantly increase construction costs.

As the eldest of the postwar baby-boomers turns 76, a generation whose rebellious spirit helped to reshape society 50 years ago is succumbing to the ills of old age and is poised to reshape healthcare in the process.

For years the failure to invest in community care has been masked by reductions in the time patients spend in hospital as technological advances have shortened recovery times.

This has allowed the NHS to deliver more care despite losing around 50 per cent of its beds since the early 1990s. However, hospital stays in England are among the shortest in the OECD club of rich nations, leaving little scope for further reductions.

Even before the Covid pandemic triggered further demand, bed occupancy was running at up to 90 per cent, significantly higher than the level considered safe.

A ‘profound dissonance’

The baby-boomers’ intensifying medical needs have highlighted a lack of co-ordination between different parts of the health and care system.

Charlesworth said: “While we have excellence in parts of our system, what we have failed to do, despite it being the intention of policymakers for over two decades, is to really join up general practice, hospital care, community-based services and the social care system.”

She lamented “a profound dissonance” between the rhetoric of strengthening community services and the reality of how resources had been allocated.

“We’ve got one in 10 fewer nurses working in the community today than we had a decade ago. How on earth can we possibly deliver the sort of seamless home-based care that we’re talking about?” she said.

A fresh approach

In the Netherlands, a different model has been developed over the past two decades. Dutch data show the percentage of people dying at home rose from 36 per cent in 2015 to 41 per cent in 2020. Meanwhile, the number of those dying in hospital fell from 25 per cent in 2010 to 18 per cent a decade later.

In the UK, in contrast, more than 45 per cent of people die in hospital, according to pre-pandemic data.

Professor Saskia Teunissen, who runs the Netherlands Institute for Palliative Care, said that since 2000 the country had been developing a more unified approach to the final year of life — the time when patients make maximum demands on the health system.

Part of what triggered the rethink was the passage of a law on euthanasia in 2002 which focused attention on the level of support available for those coming to the end of their lives.

“The most important difference between the philosophy in the Netherlands and the rest of Europe, and a major part of the world, is that here palliative medicine is not regarded as a separate discipline but is integrated into the total package of care for a patient, beginning with the initial diagnosis,” she said.

Whereas in the UK, patients would be referred to palliative medicine at the end of life, “that’s quite different from how it works with us where palliative consultants [are part of] a multidisciplinary or an inter-professional team in primary care,” she added.

Professor Thijs Merkx, a surgeon who runs the Netherlands’ Comprehensive Cancer Organisation, which oversees research into oncological and palliative care said that 16 years ago the government had chosen to prioritise investment in out-of-hospital care. This followed a decade in which funding for that area had been outstripped by support for inpatient and outpatient medical services, he added.

Typically, once patients’ conditions become incurable they are visited by specialist GPs and nurses who discuss where they would like to end their lives, ensure symptoms are managed and that support is in place.

Ginette Hesselmann, a nurse specialist at Utrecht University Medical Centre, said the support offered is four-dimensional: “physical, social, psychological and existential”.

Hospices are an important part of the structure and unlike in the UK, where they exist on precarious charitable funding despite the key role they play in supporting NHS patients, in the Netherlands they are publicly funded.

Cathelijne Verboeket-Crul, a nurse practitioner, is based at the Demeter Hospice, a former farm on the outskirts of Utrecht. She is part of a team that supports patients in receiving care in their own homes.

In order to identify patients who can be helped by the programme, she said, clinicians apply the “surprise question”, that is, “would it surprise you if patients will die [within a] year?”.

If the answer is “no”, either a GP or a nurse practitioner visits the patient each week. “[We] speak together and we share what we notice,” said Verboeket-Crul. Once the patient enters the terminal phase, they receive a daily visit.

The Netherlands is not immune to the staffing pressures experienced by the UK. Significant numbers of nursing homes have closed in recent years and the country has a chronic shortage of homecare nurses. As in the UK, GPs are also struggling with an increasing burden of day-to-day care.

Teunissen said her organisation is working with the ministry of health to develop a more “sustainable” model that would place greater control in the hands of GPs and offer an increased role for volunteers.

For Charlesworth, the principal lesson is that a Netherlands-style model cannot be implemented without more hospital beds, however. Without them, staff will struggle to move beyond daily firefighting to properly consider how and where patients should be cared for.

“It takes time and resources and you just can’t do that if you’re in perennial crisis,” she added.

Data by Federica Cocco